The modified Surgical Apgar Score predictive value for postoperative complications after robotic surgery for rectal cancer.

OBJECTIVE: The Surgical Apgar Score quantifies three intraoperative parameters: lowest heart rate, lowest mean arterial pressure, and estimated blood loss (EBL). This scoring system predicts postoperative complications based on these measured factors. The aim of this study was to investigate the value of modified Surgical Apgar Score (mSAS) in predicting postoperative complications in patients with rectal cancer treated with robotic surgery in order to improve the survival and quality of life of rectal cancer patients. METHODS: The study included patients with rectal cancer who underwent robotic surgery in the Department of Gastrointestinal Surgery at the First Affiliated Hospital of Nanchang University from January 2015 to December 2023. In minimally invasive surgery, we developed a modified Surgical Apgar Score (mSAS) tailored for robotic rectal cancer surgery, incorporating an adjusted threshold for EBL. This threshold was derived from quartile analysis of a cohort of 524 patients, with a median EBL of 100 mL (IQR 80-130 mL). We analyzed the association of postoperative complications with low mSAS. RESULTS: This study included 524 patients, of which 91 (17.4%) experienced complications and 22 (4.2%) suffered severe complications. mSAS of 6 provided maximal Youden index and were determined as the cut-off values. The area under the ROC curve for predicting complications using the mSAS was 0.740. Univariate and multivariate analyses indicated that an older age, lower tumor localization, longer operation time, radiotherapy alone, combined chemoradiotherapy, and lower mSAS as independent risk factors for complications. The AUC of the prediction nomogram was 0.834 (95% CI 0.774-0.867). The calibration curve demonstrated excellent concordance with the nomogram, indicating the prediction curve ft the diagonal well. CONCLUSION: This study suggests that mSAS might be a valuable predictive indicator for postoperative complications following robotic rectal cancer surgery, with potentially higher clinical utility.

Implementation of the Surgical Apgar Score in Laboratory Animal Science: A Showcase Pilot Study in a Porcine Model and a Review of the Literature.

INTRODUCTION: In an attempt to further improve surgical outcomes, a variety of outcome prediction and risk-assessment tools have been developed for the clinical setting. Risk scores such as the surgical Apgar score (SAS) hold promise to facilitate the objective assessment of perioperative risk related to comorbidities of the patients or the individual characteristics of the surgical procedure itself. Despite the large number of scoring models in clinical surgery, only very few of these models have ever been utilized in the setting of laboratory animal science. The SAS has been validated in various clinical surgical procedures and shown to be strongly associated with postoperative morbidity. In the present study, we aimed to review the clinical evidence supporting the use of the SAS system and performed a showcase pilot trial in a large animal model as the first implementation of a porcine-adapted SAS (pSAS) in an in vivo laboratory animal science setting. METHODS: A literature review was performed in the PubMed and Embase databases. Study characteristics and results using the SAS were reported. For the in vivo study, 21 female German landrace pigs have been used either to study bleeding analogy (n = 9) or to apply pSAS after abdominal surgery in a kidney transplant model (n = 12). The SAS was calculated using 3 criteria: (1) estimated blood loss during surgery; (2) lowest mean arterial blood pressure; and (3) lowest heart rate. RESULTS: The SAS has been verified to be an effective tool in numerous clinical studies of abdominal surgery, regardless of specialization confirming independence on the type of surgical field or the choice of surgery. Thresholds for blood loss assessment were species specifically adjusted to >700 mL = score 0; 700-400 mL = score 1; 400-55 mL score 2; and <55 mL = score 3 resulting in a species-specific pSAS for a more precise classification. CONCLUSION: Our literature review demonstrates the feasibility and excellent performance of the SAS in various clinical settings. Within this pilot study, we could demonstrate the usefulness of the modified SAS (pSAS) in a porcine kidney transplantation model. The SAS has a potential to facilitate early veterinary intervention and drive the perioperative care in large animal models exemplified in a case study using pigs. Further larger studies are warranted to validate our findings.

The surgical Apgar score predicts postoperative complications and the survival in lung cancer patients.

PURPOSE: The surgical Apgar score (SAS)-calculated using the intraoperative variables estimated blood loss, lowest heart rate, and lowest mean systolic pressure-is associated with mortality in cancer surgery. We investigated the utility of the SAS in patients with lung cancer undergoing surgery. METHODS: We retrospectively analyzed the data of 691 patients who underwent surgery for primary lung cancer between 2015 and 2019 in a single institute and analyzed the impact of the SAS. RESULTS: Of the 691 patients, 138 (20%), 57 (8.2%), and 7 (1.0%) had postoperative complications of all grades, grades ≥ III, and grade V, respectively, according to the Clavien-Dindo classification. The C-index for postoperative complications of grades ≥ III was 0.605. A lower score (0-5 points) (odds ratio 3.09 against 8-10 points, P = 0.04) and a lower percentage of vital capacity (odds ratio 0.97, P = 0.04) were independent negative risk factors for major postoperative complications. Patients with a lower score (0-5 points) had poor 5-year overall and cancer-specific survival rates (60.1% and 72.3%, respectively; P < 0.05 for both). CONCLUSIONS: The surgical Apgar score predicted postoperative complications and the long-term survival. Surgeons may improve surgical results using the SAS.

Ability to predict surgical outcomes by surgical Apgar score: a systematic review.

BACKGROUND: The Surgical Apgar score (SAS) is a straightforward and unbiased measure to assess the probability of experiencing complications after surgery. It is calculated upon completion of the surgical procedure and provides valuable predictive information. The SAS evaluates three specific factors during surgery: the estimated amount of blood loss (EBL), the lowest recorded mean arterial pressure (MAP), and the lowest heart rate (LHR) observed. Considering these factors, the SAS offers insights into the probability of encountering postoperative complications. METHODS: Three authors independently searched the Medline, PubMed, Web of Science, Scopus, and Embase databases until June 2022. This search was conducted without any language or timeframe restrictions, and it aimed to cover relevant literature on the subject. The inclusion criteria were the correlation between SAS and any modified/adjusted SAS (m SAS, (Modified SAS). eSAS, M eSAS, and SASA), and complications before, during, and after surgeries. Nevertheless, the study excluded letters to the editor, reviews, and case reports. Additionally, the researchers employed Begg and Egger's regression model to evaluate publication bias. RESULTS: In this systematic study, a total of 78 studies \were examined. The findings exposed that SAS was effective in anticipating short-term complications and served as factor for a long-term prognostic following multiple surgeries. While the SAS has been validated across various surgical subspecialties, based on the available evidence, the algorithm's modifications may be necessary to enhance its predictive accuracy within each specific subspecialty. CONCLUSIONS: The SAS enables surgeons and anesthesiologists to recognize patients at a higher risk for certain complications or adverse events. By either modifying the SAS (Modified SAS) or combining it with ASA criteria, healthcare professionals can enhance their ability to identify patients who require continuous observation and follow-up as they go through the postoperative period. This approach would improve the accuracy of identifying individuals at risk and ensure appropriate measures to provide necessary care and support.

Surgical Apgar Score can accurately predict the severity of post-operative complications following emergency laparotomy.

BACKGROUND: The Surgical Apgar Score (SAS) describes a feasible and objective tool for predicting surgical outcomes. However, the accuracy of the score and its correlation with the complication severity has not been well established in many grounds of low resource settings. OBJECTIVE: To determine the accuracy of Surgical Apgar Score in predicting the severity of post-operative complications among patients undergoing emergency laparotomy at Muhimbili National Hospital. METHODS: A prospective cohort study was conducted for a period of 12 months; patients were followed for 30 days, the risk of complication was classified using the Surgical Apgar Score (SAS), severity of complication was estimated using the Clavien Dindo Classification (CDC) grading scheme and Comprehensive Complication Index (CCI). Spearman correlation and simple linear regression statistic models were applied to establish the relationship between Surgical Apgar Score (SAS) and Comprehensive Complication Index (CCI). The Accuracy of SAS was evaluated by determining its discriminatory capacity on Receiver Operating Characteristics (ROC) curve, data normality was tested by Shapiro-Wilk statistic 0.929 (p < 0.001).Analysis was done using International Business Machine Statistical Product and Service Solution (IBM SPSS) version 27. RESULTS: Out of the 111 patients who underwent emergency laparotomy, 71 (64%) were Male and the median age (IQR) was 49 (36, 59).The mean SAS was 4.86 (± 1.29) and the median CCI (IQR) was 36.20 (26.2, 42.40). Patients in the high-risk SAS group (0-4) were more likely to experience severe and life-threatening complications, with a mean CCI of 53.3 (95% CI: 47.2-63.4), compared to the low-risk SAS group (7-10) with a mean CCI of 21.0 (95% CI: 5.3-36.2). A negative correlation was observed between SAS and CCI, with a Spearman r of -0.575 (p < 0.001) and a regression coefficient b of -11.5 (p < 0.001). The SAS demonstrated good accuracy in predicting post-operative complications, with an area under the curve of 0.712 (95% CI: 0.523-0.902, p < 0.001) on the ROC. CONCLUSION: This study has demonstrated that SAS can accurately predict the occurrence of complications following emergency laparotomy at Muhimbili National Hospital.

The impact of the surgical Apgar score on oncological outcomes in patients with colorectal cancer: a propensity score-matched study.

BACKGROUND: The surgical Apgar score (SAS) predicts postoperative complications (POCs) following gastrointestinal surgery. Recently, the SAS was reported to be a predictor of not only POCs but also prognosis. However, the impact of the SAS on oncological outcomes in patients with colorectal cancer (CRC) has not been fully examined. The present study therefore explored the oncological significance of the SAS in patients with CRC, using a propensity score matching (PSM) method. METHODS: We retrospectively analyzed 639 patients who underwent radical surgery for CRC. The SAS was calculated based on three intraoperative parameters: estimated blood loss, lowest mean arterial pressure, and lowest heart rate. All patients were classified into 2 groups based on the SAS (≤6 and >6). The association of the SAS with the recurrence-free survival (RFS), overall survival (OS), and cancer-specific survival (CSS) was analyzed. RESULTS: After PSM, each group included 156 patients. Univariate analyses revealed that a lower SAS (≤6) was significantly associated with a worse OS and CSS. A multivariate analysis revealed that the age ≥75 years old, ASA-Physical Status ≥3, SAS ≤6, histologically undifferentiated tumor type, and an advanced pStage were independent factors for the OS, and open surgery, a SAS ≤6, histologically undifferentiated tumor type and advanced pStage were independent factors for the CSS. CONCLUSIONS: A lower SAS (≤6) was an independent prognostic factor for not only the OS but also the CSS in patients with CRC, suggesting that the SAS might be a useful biomarker predicting oncological outcomes in patients with CRC.

Surgical Apgar score as a predictor of outcomes in patients following laparotomy at Mulago National Referral Hospital, Uganda: a prospective cohort study.

BACKGROUND: Postoperative complications and mortality following laparotomy have remained high worldwide. Early postoperative risk stratification is essential to improve outcomes and clinical care. The surgical Apgar score (SAS) is a simple and objective bedside prediction tool that can guide a surgeon's postoperative decision making. The objective of this study was to evaluate the performance of SAS in predicting outcomes in patients undergoing laparotomy at Mulago hospital. METHOD: A prospective observational study was conducted among eligible adult patients undergoing laparotomy at Mulago hospital and followed up for 4 months. We collected data on the patient's preoperative and intraoperative characteristics. Using the data generated, SAS was calculated, and patients were classified into 3 groups namely: low (8-10), medium (5-7), and high (0-4). Primary outcomes were in-hospital major complications and mortality. Data was presented as proportions or mean (standard deviation) or median (interquartile range) as appropriate. We used inferential statistics to determine the association between the SAS and the primary outcomes while the SAS discriminatory ability was determined from the receiver-operating curve (ROC) analysis. RESULTS: Of the 151 participants recruited, 103 (68.2%) were male and the mean age was 40.6 ± 15. Overall postoperative in-hospital major complications and mortality rates were 24.2% and 10.6%, respectively. The participants with a high SAS category had an18.4 times risk (95% CI, 1.9-177, p = 0.012) of developing major complications, while those in medium SAS category had 3.9 times risk (95% CI, 1.01-15.26, p = 0.048) of dying. SAS had a fair discriminatory ability for in-hospital major complications and mortality with the area under the curve of 0.75 and 0.77, respectively. The sensitivity and specificity of SAS ≤ 6 for major complications were 60.5% and 81.14% respectively, and for death 54.8% and 81.3%, respectively. CONCLUSION: SAS of ≤ 6 is associated with an increased risk of major complications and/or mortality. SAS has a high specificity with an overall fair discriminatory ability of predicting the risk of developing in-hospital major complications and/or death following laparotomy.

Surgical Apgar Score predictive value for early postoperative organ dysfunction in cancer patients.

BACKGROUND: Surgical APGAR Score (SAS) is based only on intraoperative data and has the advantage of being easy to calculate. Low SAS was associated with an increased risk for postoperative complications, but its utility for specific outcomes prediction, such as postoperative cardiovascular, renal, or metabolic dysfunction is less investigated. Our study aimed to investigate SAS predictive value for early postoperative organ dysfunction in a surgical oncological population. METHODS: This is a prospective observational study that enrolled all consecutive patients submitted to oncologic surgery over 20-days. Registered parameters included demographics, comorbidities, diagnosis and surgery data, SAS score, postoperative complications, organ dysfunction and in-hospital mortality. SAS predictive value for postoperative organ dysfunction was assessed using logistic regression and ROC curves. RESULTS: The study included 205 oncological patients with a mean age (standard deviation) of 60 (12.8) years. SAS was between 8 and 10 in 60% of patients and between 0 and 7 in 40% of patients. Postoperative complications developed in 33 patients (16.1%) and organ dysfunction in 26 patients (12.7%). The rates of postoperative complications, organ dysfunction and mortality, were significantly higher in patients with a low SAS (0-7) than high SAS (8-10). SAS had a low discrimination capacity to distinguish between patients who will develop postoperative complications and those who will not (AUROC 0.65) but was more accurate in identifying surgical oncological patients at risk for cardiovascular and metabolic dysfunction (AUROC 0.83 and 0.85 respectively). CONCLUSION: SAS may be a useful tool to identify cancer surgery patients at risk for postoperative cardiovascular and metabolic dysfunction.

Perioperative Risk Stratification: A Need for an Improved Assessment in Surgery and Anesthesia-A Pilot Study.

Background and Objectives: Numerous scoring systems have been introduced into modern medicine. None of the scoring systems assessed both anesthetic and surgical risk of the patient, predict the morbidity, mortality, or the need for postoperative intensive care unit admission. The aim of this study was to compare the anesthetic and surgical scores currently used, for a better evaluation of perioperative risks, morbidity, and mortality. Material and Methods: This is a pilot, prospective, observational study. We enrolled 50 patients scheduled for elective surgery. Anesthetic and surgery risk was assessed using American Society of Anesthesiologists (ASA) scale, Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM), Acute Physiology and Chronic Health Evaluation (APACHE II), and Surgical APGAR Score (SAS) scores. The real and the estimated length of stay (LOS) were registered. Results: We obtained several statistically significant positive correlations: ASA score-P-POSSUM (p < 0.01, r = 0.465); ASA score-SAS, (p < 0.01, r = -0.446); ASA score-APACHE II, (p < 0.01 r = 0.519); predicted LOS and ASA score (p < 0.01, r = 0.676); predicted LOS and p-POSSUM (p < 0.01, r = 0.433); and predicted LOS and APACHE II (p < 0.01, r = 0.454). A significant negative correlation between predicted LOS, real LOS, ASA class, and SAS (p < 0.05) was observed. We found a statistically significant difference between the predicted and actual LOS (p < 001). Conclusions: Anesthetic, surgical, and severity scores, used together, provide clearer information about mortality, morbidity, and LOS. ASA scale, associated with surgical scores and severity scores, presents a better image of the patient's progress in the perioperative period. In our study, APACHE II is the best predictor of mortality, followed by P-POSSUM and SAS. P-POSSUM score and ASA scale may be complementary in terms of preoperative physiological factors, providing valuable information for postoperative outcomes.

Predictive value of the surgical Apgar score on postoperative complications in advanced gastric cancer patients treated with neoadjuvant chemotherapy followed by radical gastrectomy: a single-center retrospective study.

BACKGROUND: The surgical Apgar score (SAS) or modified SAS (mSAS) has been reported as a simple and easy risk assessment system for predicting postoperative complications in primary surgery for gastric cancer. However, few studies have described the SAS's utility in gastric surgery after neoadjuvant chemotherapy (NAC). METHODS: One hundred and fifteen patients who received NAC and radical gastrectomy from 2008 and 2015 were included in this study. The SAS was determined by the estimated blood loss (EBL), lowest intraoperative mean arterial pressure, and lowest heart rate. The mSAS was determined by the EBL reassessed using the interquartile values. The predictive values of the SAS/mSAS for postoperative complications were assessed with univariate and multiple logistic regression analyses. RESULTS: Among the 115 patients, 41 (35.7%) developed postoperative complications. According to analyses with receiver operating characteristic curves of the SAS and mSAS for predicting postoperative complications, the cut-off value of the mSAS was set at 8. The rates of anastomotic leakage, pancreatic fistula, and arrhythmia in patients with high mSAS (> 8) values were higher than in those with low (0-3) and moderate [1-4] mSAS values. A multiple logistic regression analysis showed that the operation time, body mass index, and diabetes mellitus were independent risk factors for postoperative complications. The mSAS was not a significant predictor. CONCLUSION: The predictive value of SAS or mSAS for morbidity may be limited in patients who undergo gastric cancer surgery after NAC. Future prospective studies with a large sample size will be needed to confirm the present results.

Usefulness of scoring systems in outcome prediction for older cancer patients undergoing abdominal surgery.

BACKGROUND: Several postoperative outcome scoring systems have been developed and validated, combining both pre- and intraoperative factors. Among others are the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM), the Estimation of Physiologic Ability and Stress (E-PASS) and the Surgical Apgar Score combined with the American Society of Anesthesiologists physical status classification (SASA). The aim of this study was to compare the above scoring systems in the prediction of 30-day postoperative outcome in older patients with cancer undergoing abdominal surgery. METHODS: Consecutive patients ≥70 years were prospectively enrolled. Pre- and intraoperative variables were used to calculate the scores, the ROC and perform logistic regression analysis. RESULTS: The study sample comprised 201 patients with a median age of 77 (range 70-93) years. The most common surgical procedure was for colorectal (75%), followed by gastric (10.4%) pancreas (7.0%), gall bladder (3.5%), small bowel (2.5%), and other (1.5%) types of cancer. All scores were independent predictors of 30-day postoperative mortality. In case of 30-day morbidity only SASA turned to be significant. The ROC curves were highly valid and area under the curve showed fair to good discriminatory ability (0.60-0.77) for 30-day postoperative mortality and fair (AUC 0.6) in case of SASA for the 30-day postoperative. CONCLUSION: The SASA, E-PASS, and P-POSSUM were confirmed to be predictive of 30-day postoperative mortality in older patients undergoing abdominal elective cancer surgery. Only SASA demonstrated as independent factor predicting postoperative 30-day major morbidity.

Prediction of perioperative complications after robotic-assisted radical hysterectomy for cervical cancer using the modified surgical Apgar score.

BACKGROUND: Although there has been marked development in surgical techniques, there is no easy and fast method of predicting complications in minimally invasive surgeries. We evaluated whether the modified surgical Apgar score (MSAS) could predict perioperative complications in patients undergoing robotic-assisted radical hysterectomy. METHODS: All patients with cervical cancer undergoing robotic-assisted radical hysterectomy at our institution between January 2011 and May 2017 were included. Their clinical characteristics were retrieved from their medical records. The surgical Apgar score (SAS) was calculated from the estimated blood loss, lowest mean arterial pressure, and lowest heart rate during surgery. We modified the SAS considering the lesser blood loss typical of robotic surgeries. Perioperative complications were defined using a previous study and the Clavien-Dindo classification and subdivided into intraoperative and postoperative complications. We analyzed the association of perioperative complications with low MSAS. RESULTS: A total of 138 patients were divided into 2 groups: with (n = 53) and without (n = 85) complications. According to the Clavien-Dindo classification, 49 perioperative complications were classified under Grade I (73.1%); 13, under Grade II (19.4%); and 5, under Grade III (7.5%); 0, under both Grade IV and Grade V. Perioperative complications were significantly associated with surgical time (p = 0.026). The MSAS had a correlation with perioperative complications (p = 0.047). The low MSAS (MSAS, ≤6; n = 52) group had significantly more complications [40 (76.9%), p = 0.01]. Intraoperative complications were more correlated with a low MSAS than were postoperative complications [1 (1.2%) vs. 21 (40.4%); p < 0.001, 13 (15.1%) vs. 25 (48.1%); p = 0.29, respectively]. We also analyzed the risk-stratified MSAS in 3 subgroups: low (MSAS, 7-10), moderate (MSAS 5-6), and high risks (MSAS, 0-4). The prevalence of intraoperative complications significantly increased as the MSAS decreased p = 0.01). CONCLUSIONS: This study was consistent the concept that the intuitive and simple MSAS might be more useful in predicting intraoperative complications than in predicting postoperative complications in minimally invasive surgeries, such as robotic-assisted radical hysterectomy for cervical cancer.

Surgical Apgar score for predicting complications after hepatectomy for hepatocellular carcinoma.

BACKGROUND: Surgical Apgar score (SAS) was recently proposed as a simple predictor of postoperative complications. A few studies have shown the utility of the SAS in some kinds of surgeries, but it has not been investigated in patients undergoing hepatectomy for hepatocellular carcinoma (HCC). METHODS: This study included 158 patients undergoing hepatectomy for HCC. The association between SAS and postoperative complications was examined. The patients had postoperative morbidities classified as Clavien-Dindo grade II or higher. Multivariate regression analysis was performed to identify independent factors that significantly influenced the development of postoperative complications. RESULTS: Postoperative complications developed in 28 (17.7%) of the 158 patients. The proportion of cases with complications was significantly inversely correlated with SAS (Spearman rank correlation 0.829). The SAS was significantly lower in cases with complications than those without complications (5.6 ± 1.3 points versus 6.6 ± 1.3 points, P = 0.0004). Comparisons between patients with and without complication showed that preoperative serum albumin level and operation time, as well as SAS, were associated with complications. Multivariate analysis revealed that postoperative complications significantly correlated with the SAS. CONCLUSIONS: This study demonstrated the clinical utility of SAS in predicting the development of postoperative complications after hepatectomy for HCC.

Does the Surgical Apgar Score predict serious complications after elective major cancer surgery?

BACKGROUND: Major cancer surgery is associated with significant risks of perioperative morbidity and mortality, resulting in delayed adjuvant therapy, higher recurrence rates, and worse overall survival. Previous retrospective studies have used the Surgical Apgar Score (SAS) for perioperative risk assessment. This study prospectively evaluated the predictive value of SAS to predict serious complication (SC) after elective major cancer surgery. METHODS: Demographic, comorbidity, procedure, and intraoperative data were collected prospectively for 405 patients undergoing elective major cancer surgery between 2014-17. The SAS was calculated immediately postoperative and outcome data were collected prospectively. Rates of SC according to SAS risk category were compared using Cochran-Armitage trend test. Receiver operating characteristic curves and area under the receiver operating characteristic curves were generated and 95% confidence intervals were calculated. RESULTS: Eighty percent, 17.3%, and 2.7% of patients were low (SAS 7-10), intermediate (SAS 5-6), and high risk (SAS 0-4), respectively, for SC based on their SAS. Forty-six (11.4%) had an SC within 30 days; 3.7% returned to the operating room, 3.7% experienced a urinary tract infection, 3.2% experienced a respiratory complication, 2.7% experienced a wound complication, and 1.2% experienced a cardiac complication. Overall, 9.3%, 18.6%, and 27.3% of patients with SAS 7-10, 5-6, and 0-4 experienced an SC, respectively (P = 0.005). The overall discriminatory ability of the SAS was modest (area under the receiver operating characteristic curves 0.661; 95% confidence intervals, 0.582-0.740). CONCLUSIONS: Although there was an overall association between SAS and higher risk of subsequent postoperative SC in our cohort, the ability of the SAS to accurately predict risk of postoperative SC at the patient level was limited.

Surgical Apgar score (SAS) predicts perioperative morbidity, mortality, and length of stay in patients undergoing esophagectomy at a high-volume center.

BACKGROUND: Esophagectomy carries considerable morbidity. Many studies have evaluated factors to predict patients at risk. This study aimed to determine whether the surgical Apgar score (SAS) predicts complications and length of stay (LOS) for patients undergoing esophagectomy. STUDY DESIGN: We evaluated 212 patients undergoing esophagectomy. Postoperative complications were graded using the Clavien-Dindo scale and the SAS was determined. Association of SAS with incidence of complications was evaluated using the Cochran-Armitage trend test between grouped SAS scores (0-2, 3-4, 5-6, 7-8, 9-10) and each of the outcomes. Correlation of SAS with LOS was evaluated using competing risks proportional hazards regression. RESULTS: The average patient age was 63.5 years (range 31-86), and the average blood loss was 284 mL (range 50-4000). The median LOS was 10 days. There was a significant association between SAS and grade 2 or higher (P = 0.0002) and grade 3 or higher (P < 0.0001) complications. The perioperative mortality rate was 5.2% (n = 11) with lower SAS being associated with greater mortality. LOS was also associated with SAS (P < 0.0001). CONCLUSIONS: We demonstrate that SAS is a significant predictor of complications and LOS for patients undergoing esophagectomy. SAS should be used to identify lower risk patients to prioritize use of critical care beds and hospital resources.

New surgical scoring system to predict postoperative mortality.

PURPOSE: There is still no easy and highly useful method to comprehensively assess both preoperative and intraoperative patient statuses to predict postoperative outcomes. We attempted to develop a new scoring system that would enable a comprehensive assessment of preoperative and intraoperative patient statuses instantly at the end of anesthesia, predicting postoperative mortality. METHODS: The study included 32,555 patients who underwent surgery under general or regional anesthesia from 2008 to 2012. From the anesthesia records, extracted factors, including patient characteristics and American Society of Anesthesiologists physical status classification (ASA-PS), and three intraoperative indexes (the lowest heart rate, lowest mean arterial pressure, and estimated volume of blood loss) are used to calculate the surgical Apgar score (sAs). The sAs and ASA-PS, and surgical Apgar score combined with American Society of Anesthesiologists physical status classification (SASA), which combines the sAs and ASA-PS into a single adjusted scale, were compared and analyzed with postoperative 30-day mortality. RESULTS: Increased severity of the sAs, ASA-PS and SASA was correlated with significantly higher mortality. The risk of death was elevated by 3.65 for every 2-point decrease in the sAs, by 6.4 for every 1-point increase in the ASA-PS, and by 9.56 for every 4-point decrease in the SASA. The ROC curves of the sAs and ASA-PS alone also individually demonstrated high validity (AUC = 0.81 for sAs and 0.79 for ASA-PS, P < 0.001). The SASA was even more valid (AUC = 0.87, P < 0.001). CONCLUSIONS: The sAs and ASA-PS were shown to be extremely useful for predicting 30-day mortality after surgery. An even higher predictive ability was demonstrated by the SASA, which combines these simple and effective scoring systems.

Utility of the Surgical Apgar Score in Kidney Transplantation: Is it Feasible to Predict ICU Admission, Hospital Readmission, Length of Stay, and Cost in This Patient Population?

BACKGROUND: This study analyzed the utility of the Surgical Apgar Scoring (SAS) system in predicting morbidity in kidney transplantation. Recipient comorbidities were evaluated for any effect on the SAS and then globally assessed for any relationship with intensive care unit (ICU) admission, need for dialysis, creatinine at discharge, length of stay, incremental, and total cost of transplantation. The hypothesis for this study is that a low SAS will be a statistically significant predictor of postoperative morbidity and associated costs. METHODS: This was an institutional review board (IRB)-approved retrospective longitudinal cohort study on 204 solitary kidney transplant recipients (2009-2011). Patients were divided into 2 groups: low to moderate = SAS ≤ 7 and high = SAS ≥ 8. These groups were then analyzed against a host of variables. RESULTS: Sixty-five percent of patients had an SAS of 7 or lower, while 35% had an SAS of 8 and higher. Recipients with a history of stroke were 88% more likely to be in the low-moderate SAS group (P = .017). Patients with lower SASs trended toward having less extended criteria donors (0.097) but were more likely to be admitted to the ICU (P = .043), leading to significantly higher transplant event hospitalization costs. Higher SASs were more likely to be readmitted to the hospital within 30 days of discharge (P = .027), leading to higher 30-day postdischarge costs (P = .014). Readmission rates, however, and 30-day follow-up costs were similar between SAS groups after controlling for donor characteristics, specifically donor marginality and recipient estimated glomerular filtration rate (eGFR). CONCLUSION: The findings of this study suggest that a history of stroke in the recipient may lend to a lower SAS and that a low SAS is associated with ICU admission following transplant, leading to higher hospital costs.

Plasma BNP level combined with surgical Apgar score to predict operative major cardiac adverse events in malignant obstructive jaundice patients.

OBJECTIVE: To investigate the predictive effect of major adverse cardiac events (MACE) in malignant obstructive jaundice (OJ) patients using plasma brain natriuretic peptide (BNP) level and surgical Apgar scoring (SAS) system. METHODS: Forty one malignant OJ patients undergoing surgical treatments were studied at a single center. Pre-and postoperative plasma BNP level, total bilirubin (TBil) and data of cardiac function (HR, CVP, CI, LVEF%) were detected, the SAS was calculated during the surgery, the relationship of both plasma BNP level and SAS with MACE after surgery was analyzed. RESULTS: Thirteen patients out of 41 (31.71%) experienced MACE without cardiac death. OJ patients had a higher plasma BNP level than baseline before operation (191.61±105.76 pg/ml VS 175 pg/ml, P<0.05), the cardiac function data was improved (CVP: t=4.761, p=0.000; CI: t=3.539, p=0.001; LVEF%: t=3.632, p=0.001) after the operation. Patients with lower SAS had increasing incidence of MACE after surgery. CONCLUSION: Malignant OJ patients with higher preoperative BNP level and lower surgical Apgar score were identified at high risk of MACE after surgery.

Surgical Apgar Score and prediction of morbidity in women undergoing hysterectomy for malignancy.

OBJECTIVE: To validate whether Surgical Apgar Score can predict post-operative morbidity in patients undergoing hysterectomies for malignancies. METHODS: We conducted a retrospective cohort study of consecutive hysterectomies performed for cancer at a single academic institution between 2008 and 2010. The Surgical Apgar Score (SAS) was derived as previously reported. Peri-operative complications were as outlined by the American Board for Obstetrics and Gynecology, and then further subdivided into intra-operative and post-operative events. Univariate and multivariate logistic regressions were utilized. RESULTS: A total of 632 patients were identified. Of our cohort, 64% underwent surgery for cancer arising in the uterus, followed by ovary at 28.6% and cervix at 4%. Median patient age was 60 years old with a mean American Society of Anesthesiologists Physical Status Classification System (ASA) score of 2.5 and a median body mass index of 29. Average Surgical Apgar Score was 7.6. As SAS decreased, the risk of peri-operative complications increased (p<0.01). On univariate analysis SAS could predict for both intra-operative and post-operative complications. However, on multivariate analyses SAS could not independently predict for any post-operative complications (OR 1.02, CI 0.47-2.17). In a multivariable model incorporating age, ASA class, SAS <4, disease site, bowel resection and laparotomy, only ASA class and laparotomy were able to predict for postoperative complication events. CONCLUSIONS: Low Surgical Apgar Score significantly associates with morbidity in women undergoing hysterectomy for malignancy, but is unable to predict which patients will have postoperative complications. This renders the SAS less helpful for the creation of peri-operative metrics to guide post-operative care.

Esophageal surgical Apgar score (eSAS): A predictor for postoperative morbidity in patients undergoing neoadjuvant therapy and esophagectomy.

BACKGROUND: The surgical Apgar score (SAS) quantifying three intraoperative indexes has been confirmed to be significantly associated with postoperative morbidity and prognosis in many surgical specialties. However, there are great limitations in its application for esophageal cancer (EC). This study aimed to assess the predictive capability of esophagectomy SAS (eSAS) in determining postoperative morbidity and overall survival (OS) in EC patients who had undergone neoadjuvant therapy. METHODS: A retrospective evaluation was conducted on a cohort of 221 patients in which surgery- and tumor-related data were extracted and analyzed. Major morbidity was defined as complications meeting the criteria of Clavien-Dindo classification III or higher during hospitalization. Univariate and multivariate analyses were performed to identify potential risk factors for major morbidity. Kaplan-Meier analysis was utilized to calculate the OS and relapse-free survival (RFS). RESULTS: The results exhibited that eSAS demonstrated potential predictive value for postoperative morbidity with an optimal cutoff value of 6. The eSAS and diabetes mellitus were two independent risk factors for the major morbidity; however, no correlation between the eSAS and the OS or RFS was detected. CONCLUSION: The eSAS could be used as a predictor of major morbidity, while it was not correlated with OS and RFS.